Effect of the molecular adsorbent recirculating system and Prometheus devices on systemic haemodynamics and vasoactive agents in patients with acute-on-chronic alcoholic liver failure

Introduction Patients with acute-on-chronic liver failure show an aggravated hyperdynamic circulation. We evaluated, in a controlled manner, potential changes in systemic haemodynamics induced by the molecular adsorbent recirculating system (MARS) and the Prometheus system liver detoxification devices in a group of patients with acute-on-chronic liver failure. Methods Eighteen patients (51.2 +/- 2.3 years old; Child - Pugh score, 12.5 +/- 0.2; Maddrey score, 63.1 +/- 5.0; hepatic venous pressure gradient, 17.6 +/- 0.9 mmHg) with biopsy-proven alcoholic cirrhosis and superimposed alcoholic hepatitis were either treated with standard medical therapy (SMT) combined with MARS (n = 6) or Prometheus ( n = 6) or were treated with SMT alone ( n = 6) on three consecutive days ( 6 hours/session). Liver tests, systemic haemodynamics and vasoactive substances were determined before and after each session. Results Groups were comparable for baseline haemodynamics and levels of vasoactive substances. Both MARS and Prometheus decreased serum bilirubin levels ( P < 0.005 versus SMT), the Prometheus device being more effective than MARS ( P = 0.002). Only MARS showed significant improvement in the mean arterial pressure (Delta change, + 9 +/- 2.4 mmHg versus - 0.3 +/- 2.4 mmHg with Prometheus and - 5.2 +/- 2.1 mmHg with SMT, P < 0.05) and in the systemic vascular resistance index (Delta change, + 131.5 +/- 46.2 dyne. s/ cm(5)/ m(2) versus - 92.8 +/- 85.2 dyne. s/ cm(5)/ m(2)with Prometheus and - 30.7 +/- 32.5 dyne. s/ cm(5)/ m(2) with SMT; P < 0.05), while the cardiac index and central filling remained constant. This circulatory improvement in the MARS group was paralleled by a decrease in plasma renin activity ( P < 0.05), aldosterone ( P < 0.03), norepinephrine ( P < 0.05), vasopressin ( P = 0.005) and nitrate/nitrite levels ( P < 0.02). Conclusion The MARS device, and not the Prometheus device, significantly attenuates the hyperdynamic circulation in acute-on-chronic liver failure, presumably by a difference in removal rate of certain vasoactive substances. These findings suggest conspicuous conceptual differences among the albumin dialysis devices.